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The number of births declined in 2001 in the United States to 4,02,933—down 1 percent from 2000 (4,058,814), which marks the first decline following 3 consecutive years of increases, according to the National Center for Health Statistics (Natl Vital Stat Rep 2003;51(2):3–5). Births to non-Hispanic white and black mothers decreased, but births to Hispanic mothers rose 4 percent. The birth rate for teenagers dropped again to 45.8 births per 1000 women aged 15 to 19 years. The rate has declined 26 percent since 1991. Birth rates dropped for women aged 20 to 29 years, but continued to rise 1 and 2 percent to 95.2 and 41.3 per 1000, respectively, for women 30 to 34 and 35 to 39 years. The low-birthweight rate (< 2500 g) increased slightly from 7.6 to 7.7 percent from 2000 to 2001; the rate has climbed 13 percent since the mid-1980s. The twin birth rate rose 3 percent to 30.1 per 1000 in 2001; this rate has risen 33 percent since 1990.

The breastfeeding rate is increasing steadily in the United States, and in 2001 the initiation rate was 69.5 percent and the rate at 6 months of age was 32.5 percent, according to a large nationwide study conducted by the Ross Laboratories Mothers’ Survey (Pediatrics 2002;110:1103–1109). The largest increases in breastfeeding initiation were in women who were black, under 20 years of age, and without college education. Breastfeeding in the hospital and at 6 months of age was most common among women who were white or Hispanic, older, college educated, not enrolled in the Women, Infants, and Children's (WIC) supplemental nutritional program, and lived in the Mountain and Pacific states. The authors concluded, ‘‘If increases in breastfeeding continue at the current rate (approximately 2% per year), in-hospital breastfeeding in the United States should meet or exceed the Healthy People 2010 goal of 75% for the early postpartum period. However, the Healthy People 2010 goal for continued breastfeeding to 5 or 6 months of age (50%) may not be reached in every subgroup.’’

The rate of induction of labor increased again for women who had live births in the United States in 2001 to 20.5 percent, up from 19.9 percent in 2000, according to the National Center for Health Statistics (Natl Vital Stat Rep 2003;51(2):15). Electronic fetal monitoring (EFM) was the most frequently reported obstetric procedure in 2001 (84.8% in 2001, 84.0% in 2000), as in previous years. More than 67 percent of women received an ultrasound scan. Rates of other procedures reported on the birth certificate in 2001 included stimulation of labor (17.5%), tocolysis (2.1%), and amniocentesis (2.2%). The report notes that the rates of EFM, ultrasound, and other obstetric procedures may be underreported on the birth certificate.

The 2001 data from the National Hospital Discharge Survey showed a continuation of trends for obstetric procedures per 100 vaginal deliveries, including a decline of episiotomy (29.2% in 2001, 32.7% in 2000); rise in repair of current obstetric laceration (41.1% in 2001, 39.2% in 2000); rise in manually assisted delivery (32.8% in 2001, 31.3% in 2000); decline in vacuum extraction (8.0.0% in 2001, 8.4% in 2000); and decline in forceps deliveries (3.4% in 2002, 4.0 in 2000).

Midwife-attended births have increased steadily in the United States since 1975, rising from less than 1.0 percent to 8.0 percent in 2001, according to the National Center for Health Statistics (Natl Vital Stat Rep 2002;51(2):16). The percent of all births delivered by physicians in hospitals continued to decline slowly, but steadily, to 91.3 percent of all births. Almost 95 percent of the midwife-attended births were by certified nurse-midwives (CNMs). Due to misclassification, these data should be considered lower estimates on the actual number of midwife-attended births. Hispanic women were more likely to have a midwife-attended hospital birth (9.3%) than were either non-Hispanic white or black women (6.8% and 7.3%, respectively). Ninety-nine percent of births in 2001 were conducted in hospitals, and most of the out-of-hospital births were in a residence (65%); 28 percent were in a free-standing birth center.

Variation in the daily pattern of births in 2001, measured by an index of occurrence, continued to show that more births occur in U.S. hospitals on Tuesdays—13.3 percent more than on the average day, according to the National Center for Health Statistics (Natl Vital Stat Rep 2002;51(2):9–10). As previously, also, infants are less likely to be born on weekends, with the fewest births occurring on Sundays. This deficit on weekends is apparent for both vaginal and cesarean births, but is much larger for the latter, especially repeat procedures.

Women who give birth during the daytime are more likely to have obstetric interventions than those who deliver in off-peak hours, according to a study of 37,000 live births in Philadelphia hospitals between 1994 and 1997 (J Epidemiol Commun Health 2002;56:577–578). Women at risk for complications and deliveries that involved fetal distress or abnormal labor were excluded. Women who had a vaginal birth during peak hours were 43 percent more like to have a vacuum or forceps delivery, 86 percent more likely to have a medically induced labor, 10 percent more likely to have an episiotomy, and more likely to experience vaginal tears. ‘‘Busy doctors in busy hospitals may simply have less tolerance for the otherwise time-consuming natural progression of labor,’’ researchers D.A. Webb and J. Culhane concluded.

Infants discharged 1 day after birth under an early- discharge protocol in a large health maintenance organization (HMO) in Massachusetts experienced no ill effects (N Engl J Med 2002;347:2031–2038). After studying outcomes on more than 20,000 pairs of mothers and newborns covered by the HMO, researchers found that emergency room visits and hospital readmission rates after discharge did not change after the state established a longer 48-hour minimum stay in 1996. Before the minimum stay legislation the HMO normally covered only a 1-night hospital stay for mothers and infants after birth. This early discharge protocol, first implemented in 1994, also included one home visit by a nurse within 48 hours after birth. Rates of newborn hospital readmission and emergency room visits remained stable over almost 8 years, irrespective of which hospital discharge policy was in place at the time of birth. However, the percentage of newborns receiving clinical evaluations on the third or fourth day after birth (the time when problems such as jaundice and feeding difficulties are most likely to occur) dropped when the state mandate requiring a longer stay replaced the early discharge program (from about 64% to 53%).

DES Update is a new national education program, developed by the Centers for Disease Control (CDC), for health care professionals and consumers that provides information, recent research findings, and resources about diethylstilbestrol (DES). Its purpose is to raise awareness about the health risks of exposure to DES. Although DES has not been prescribed for more than 30 years, it remains a current health issue because health risks associated with DES exposure continue to be uncovered by ongoing research. Women prescribed DES while pregnant appear to have a moderately increased risk of breasts cancer. Women exposed to DES in utero (DES daughters) have an increased risk of clear cell adenocarcinoma of the vagina and cervix; they are also at increased risk for reproductive tract structural differences, pregnancy complications, and infertility. Men exposed to DES in utero (DES sons) have an increased risk of epididymal cysts and possibly other genitourinary abnormalities. Resources for health care professionals (Power Point presentation and script, case studies, review essays, CME/CEU self-study modules) and consumers (DES fact sheets, self-assessment quiz, personsal helaeht information record) are available free of charge on the CDC's DES Update web site at http://www.cdc.gov/DES or by calling toll-free in the United States at 1-888-232-6789.

Australia's cesarean delivery rate is increasing, accord- ing to a recent report, Australia's Mothers and Babies 1999, published in December, 2001, by the Australian Institute of in Health and Welfare's National Perinatal Statistics Unit. In 1999, the national cesarean birth rate was 21.9 percent. The highest rate (24.9%) was in South Australia and the lowest rate in the Australian Capital Territory (19.6%). Cesarean rates were higher among older mothers, women having their first baby, and private patients. Mothers aged 35 to 39 years, who were private patients, and who were primiparas had a cesarean rate of 44.3 percent compared with women in the same age group who had public status (34.0%). Most breech-presenting babies (82.4%) in singleton pregnancies were born by cesarean section, as were 48.7 percent of twins. Two-thirds (66.2%) of all births in 1999 were spontaneous vaginal deliveries; forceps and vacuum extraction were used in 5.6 and 5.5 percent of births, respectively; and the episiotomy rate was 15.5 percent (18.9% in Victoria, 18.7% in South Australia). Labor was spontaneous in 61.9 percent and induced in 25.9 percent of women in Australia in 1999. The complete report is available at: http://www.npsu.edu.au/ps11.pdf.

A renewed focus on ‘‘skilled attendants’’ to prevent and manage obstetric complications is a basic strategy of the World Health Organization (WHO) to reduce maternal mortality worldwide (Safe Motherhood Newsletter 2002;29(1):1–6). ‘‘Skilled attendants’’ have been defined by WHO as ‘‘people with midwifery skills (for example, midwives, doctors, and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications.’’ Recognizing that an estimated 50 percent of the women worldwide do not have access to such skilled care, WHO launched a ‘‘Making Pregnancy Safer Initiative’’ (MPR) in January 2000, which is one of 11 high-priority areas of the WHO's work and places particular emphasis on the role of skilled attendants and on providing an appropriate and unbroken chain of care. The central goal is to assist countries in strengthening their health systems and in applying lessons learned from the global action on Safe Motherhood according to their own country's needs and resources. WHO will work with countries to develop partnerships for interventions and community-based actions within the public sector, and between the public sectors and nongovernmental organizations. The WHO Making Pregnancy Safer strategy will operate at global, regional, and country levels, working through its national and international partners. Additional information the WHO initiatives and resources is available at http://www.safemotherhood.org and http://www.who.int/reproductive-health.